Attitudes, Beliefs, and Behavior

C H A P T E R

3

Attitudes, Beliefs, and Behavior Benjamin A. Bensadon Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA

INTRODUCTION Robust empirical evidence linking beliefs and behavior has been accumulating for several decades. Underpinning this research are psychological concepts including Bandura’s theory of self-efficacy (Bandura, 1997), perhaps the most widely referenced and empirically supported. Central to this theory is that individuals’ perceived competence (i.e., confidence, or self-efficacy) correlates directly and uniquely with their actual behavior. The greater a person’s self-efficacy, the more apt he or she is to view novel tasks as challenging rather than threatening, and the more likely he or she is to persevere in the face of setbacks. Conversely, those who do not feel self-efficacious in a particular domain tend to avoid related tasks out of fear. Simply put, self-efficacy represents the bridge between beliefs and behavior. Stereotypes constitute another type of belief shown to influence behavior. In 1954, Harvard psychologist Gordon Allport dedicated an entire text to the inherently human nature of prejudice (Allport, 1954). Fifteen years later geriatric physician Robert Butler applied these concepts to the elderly by coining the term ageism (Butler, 1969). He later expanded this in a seminal critique aptly titled Why Survive? Being Old in America (Butler, 1975) and was appointed director of the National Institute on Aging (NIA) of the National Institutes of Health (NIH) before going on to establish the first academic department of geriatric medicine in 1982 at New York’s Mt. Sinai School of Medicine. Research psychologists have since devised and tested several theories of stereotype impact. Two prominent examples within the geriatric population are self-stereotyping (e.g., Levy, 1996; Levy, 2000) and stereotype threat (e.g., Steele & Aronson, 1995; Steele, 1997). Although challenging

B. Bensadon (Ed): Psychology and Geriatrics. DOI: http://dx.doi.org/10.1016/B978-0-12-420123-1.00003-4

45

© 2015 2014 Elsevier Inc. All rights reserved.

46

3.  Attitudes, Beliefs, and Behavior

to simulate in a laboratory setting, emerging evidence has shown that aging stereotypes can directly impact behavior. Generally, published results have demonstrated behavior-enhancing effects of positive aging stereotypes and inhibitory effects, both direct and indirect (via anxiety), of negative aging stereotypes. Measured behavioral outcomes have included gait speed, handwriting quality, and even will to live (Levy, 2003). The above evidence has largely involved research with communitydwelling (aka nonclinical) samples of the older population. While these findings are valuable in their own right, as shown below, they are just as relevant to geriatric medicine, though common professional silos and lack of integration make this less obvious.

CLINICAL RELEVANCE Levy and colleagues (2014) recently found older people who hold more negative aging self-stereotypes had a 50% higher chance of being hospitalized over a 10-year period than those holding more positive self-stereotypes. Their earlier study with the same sample, published in Journal of the American Medical Association (JAMA), found older people holding more positive age stereotypes were 44% more likely to fully recover from disability (Levy, Slade, Murphy, & Gill, 2012). Analogously, an earlier study by Levy and colleagues reported positive age stereotypes can help reduce cardiovascular stress (Levy, Hausdorff, Hencke, & Wei, 2000). This is particularly important in light of her more recent work, which, along with geriatrician and NIA Scientific Director Luigi Ferrucci, found that negative age stereotypes held early in life actually predicted cardiovascular events up to 38 years later (Levy, Zonderman, Slade, & Ferrucci, 2009). This link between beliefs and cardiovascular health has been demonstrated for many decades. Cardiologists in the 1950s posited, tested, and demonstrated links between “type A” behavior and cardiac risk (Friedman & Rosenman, 1959). In fact, findings were convincing enough for the authors to write an entire book 15 years later titled Type A Behavior and Your Heart (Friedman & Rosenman, 1974). As noted earlier in this publication, psychologists and cardiologists may collaborate for research purposes (e.g., National Heart, Lung, & Blood Institute), but rarely is their clinical care integrated.

MEMORY The belief–behavior link and benefit of integration are particularly relevant to cognitive aging. Scientific terms such as “demented” and “senile”

PSYCHOLOGY AND GERIATRICS

Memory

47

are commonly used colloquially, mainly to describe older people unfavorably. The content of most aging-based stereotypes pertains to memory and cognition. Not surprisingly, these beliefs are often internalized by elders themselves, and can directly influence their self-evaluations of aging (Kotter-Gruhn, & Hess, 2012). In fact, some older adults rely on their perceived memory function to gauge their overall (not just cognitive) health, and the memory domain holds increasing salience as people age (Dark-Freudeman, West, & Viverito, 2006). This trend becomes more critical when considering the decades of evidence linking subjective selfreport measures of health and subsequent mortality (e.g., DeSalvo, Bloser, Reynolds, He, & Muntner, 2006; Idler & Benyamini, 1997; Mossey & Shapiro, 1982). Notably, Desalvo and Muntner (2011) analyzed related data on nearly 15,000 Americans and found not only did people’s perceived health differ from their physicians’ perceptions, but those who believed their health was worse than their physicians believed actually experienced higher rates of mortality. Memory-related self-efficacy (MSE) has been measured in different ways, but the Memory Self-Efficacy Questionnaire (MSEQ; Berry, West, & Dennehy, 1989) is most closely aligned with the theory. This tool uses 10-point Likert scales to assess an individual’s confidence in performing specific tasks of varying difficulty. These include remembering names of faces, locations of objects, excerpts from a short story, and items from a shopping list. Over several decades, psychologist and MSEQ co-author Dr. Robin West and colleagues have empirically tested the MSE-memory performance relationship (e.g., West, Bagwell, & Dark-Freudeman, 2005, 2008; West, Crook, & Barron, 1992; West, Dark-Freudeman, & Bagwell, 2009; West, Dennehy-Basile, & Norris, 1996; West, Thorn, & Bagwell, 2003; West, Welch, & Knabb, 2002; West, Welch, & Thorn, 2001; West & Yassuda, 2004). Two consistent trends have emerged from this research: 1) Memory self-efficacy and memory performance tend to decline with age, and 2) actual memory performance tends to improve as memory self-efficacy increases. Importantly, negative aging-related stereotypes can harm memory self-efficacy, especially because stereotype content is often cognition or memory-specific. Levy’s early work demonstrated the direct impact of aging self-stereotypes on memory performance (e.g., Levy & Langer, 1994). Psychologist Tom Hess and colleagues (2003, 2004, 2006, 2009) have also measured the “threat” to cognition induced by these stereotypes. Comparatively few studies (e.g., Bensadon, 2010) have examined the impact of both mechanisms – age stereotypes and MSE – on each other and older adult memory performance. What is clear, however, based on the preponderance of evidence, is that aging-related beliefs and perceptions do influence health and behavior, and memory is particularly susceptible.

PSYCHOLOGY AND GERIATRICS

48

3.  Attitudes, Beliefs, and Behavior

“Anti-Dementia” Therapy At the same time, a proliferation of medical research has focused on neurocognitive disorders such as Alzheimer’s disease, now the sixth leading cause of death nationwide and fifth among those aged 65 years and older (Centers for Disease Control and Prevention). Unfortunately, decades of costly drug trials targeting beta amyloid protein have yielded very limited evidence of benefit (Friedrich, 2012). Similarly, effectiveness of pharmacotherapy with acetylcholinesterase inhibitors (AChEI) or N-methyl-Daspartate (NMDA) antagonists for those with Alzheimer’s and related dementias (ADRD) is also limited. Literature reviews of other drugs, such as statins, have demonstrated no cognitive benefit (e.g., McGuinness et al., 2013) and some disturbing side effects (Bruckert, Hayem, Dejager, Yau, & Begaud, 2005; Golomb, McGraw, Evans, & Dimsdale, 2007). Interestingly, some of these side effects have been cognitive in nature and discontinuation of statin therapy has even led to reported reversal of dementia or Alzheimer’s diagnosis (Evans & Golomb, 2009). Furthermore, efficacy of “anti-dementia” drugs is generally defined by statistically significant improvements on measures of cognitive status, such as the widely used Mini Mental State Examination (Folstein, Folstein, & McHugh, 1975). Their clinical significance, and relevance to daily life, is unclear. Thus, the most modifiable aspects of these devastating illnesses may actually be psychosocial. Based on this evidence, some physicians have recommended abandoning the focus on amyloid entirely in order to explore new options, including more immediately available nonpharmacologic, behavioral approaches (e.g., George & Whitehouse, 2014). While such interventions have shown promise, particularly in terms of supporting family caregivers (Chien et  al., 2011; Thompson et  al., 2007), their integration with standard dementia care remains suboptimal, and community-based advocacy groups struggle to fill this gap (Reuben et  al., 2009). Importantly, related insight is not routine in medical practice, though some physicians (e.g., Reuben et al., 2010) have openly recognized this, referring to “inadequate knowledge of physicians about community resources and behavioral management needed for optimal care for patients with dementia. … Moreover, there is little time during the office visit for physicians to provide counseling and support for caregivers” (pp. 324–5). Resistance to a change in course regarding the amyloid cascade hypothesis is not surprising given the enormous financial and human resources already invested. In fact, it was psychologists Amos Tversky and Daniel Kahneman (1974) whose seminal article in the journal Science, “Judgment under Uncertainty: Heuristics and Biases,” established a cognitive basis for common human errors in judgment and decision-making. Kahneman was awarded a Nobel Prize for his work and the above article has been

PSYCHOLOGY AND GERIATRICS

Memory

49

cited more than 29,000 times. Inspired by this research, other psychologists (e.g., Arkes & Blumer, 1985) have more explicitly defined and measured the “sunk cost effect,” or tendency for people to continue an endeavor once significant investments have been made, even if, objectively, desired results are unlikely to be achieved without a change. While medicine and science emphasize rationality, human decision-making remains inherently subjective, an admission directly addressed by Cain and Detsky (2008) in a JAMA commentary titled “Everyone’s a Little Bit Biased (Even Physicians).”

Caregiver Burden In the absence of effective pharmacotherapy and with the help of psychology-geriatrics integration (Dunkin & Anderson-Hanley, 1998), physicians have begun to recognize the clinically relevant and susceptible nature of caregiver health. This extends beyond dementia, as evidenced by a recent JAMA clinical review of caregiver burden (Adelman, Tmanova, Delgado, Dion, & Lachs, 2014). These authors’ stated objectives were: “to outline the epidemiology of caregiver burden; to provide strategies to diagnose, assess, and intervene for caregiver burden in clinical practice; and to evaluate evidence on interventions intended to avert or mitigate caregiver burden and related caregiver distress” (p. 1052). Notably, the team of authors represented an array of educational backgrounds – two physicians, one veterinarian, one library scientist, and one holding a bachelor’s degree. Interestingly and significantly, it did not include a psychologist. Encouragingly though, the authors identified depression, social isolation, and lack of choice in being a caregiver as risk factors for burden. They also quantified comparable “mild to modest efficacy” for both psychosocial and pharmacologic interventions. But perhaps most informative was their final result: “Many studies showed improvements in caregiver burden-associated symptoms (e.g., mood, coping, self-efficacy), even when caregiver burden itself was minimally improved.”

This crucial distinction between objective vs. subjective burden fits precisely with the core tenets of Bandura’s and other psychologists’ longstanding theories. While the “objective” situation matters, so too does an individual’s perceived (i.e., “subjective”) ability to respond, which then contributes to the actual behavioral response that follows. Many people will be burdened with the caregiving role, but not all will experience that role as “burden.” Related health correlates (physical and mental) and perceived coping ability will vary by individual. Intrusiveness, be it of caregiving duties or of one’s own illness, pertains to beliefs (e.g., Hundt

PSYCHOLOGY AND GERIATRICS

50

3.  Attitudes, Beliefs, and Behavior

et  al., 2013). Most importantly, from an intervention standpoint, these authors’ meta-analysis showed that associated beliefs can be modified (by psychosocial and psychoeducational interventions) even when the situation cannot. As elucidated in this publication’s caregiving chapter, perceived caregiver burden and subsequent decisions to institutionalize care recipients do not necessarily correlate with severity of dementia-related behavioral problems (e.g., Zarit, Reever, & Bach-Peterson, 1980; Zarit, Todd, & Zarit, 1986). Unfortunately, this concept was not emphasized in the JAMA review. Instead, the authors concluded that physicians must recognize and assess burden, and offered specific questions (“discussion catalysts”) by which to do so. Taken together, the above examples demonstrate that for patients, family members, and their providers, especially with regard to cognitive aging, subjective beliefs and perceptions matter. Unfortunately, many medical experts in neurology, psychiatry, and geriatrics, along with “stakeholders” from diagnostic imaging and pharmaceutical industries, appear unaware of this scientific evidence. Instead, their attention has focused on identifying disease markers via earlier screening and diagnosis, regardless of the absence of evidence to support their value. A plethora of diagnostic equipment (e.g., Beta-Amyloid Positron Emission Tomography) and terminology such as cognitive impairment no dementia (CIND), age-associated memory impairment (AAMI), and mild cognitive impairment (MCI), have followed.

Mild Cognitive Impairment The term MCI, popularized by Mayo Clinic neurologist Ronald Petersen and colleagues in the 1990s (Petersen, Smith, Ivnik, Tangalos, & Kokmen, 1994; Petersen, Smith, Waring, et  al., 1999; Smith, et  al., 1996), is increasingly believed, though not proven, to be a “prodromal” form of dementia, an intermediate stage between normal cognition and eventual dementia (see review by Bensadon & Odenheimer, 2013). Those favoring this classification emphasize the prudence of earlier identification of those at risk for developing Alzheimer’s disease and related disorders (e.g., Gauthier et  al., 2006; Petersen et  al., 2009). This label remains controversial, however, as data from population-based studies have consistently shown that many individuals diagnosed with MCI do not progress to dementia and may even revert back to premorbid, baseline (aka “normal”) functioning (Perri, Carlesimo, Serra, & Caltagirone, 2009; Perri, Serra, Carlesimo, & Caltagirone, 2007). Data revealing similar prognostic uncertainty have been published by Petersen and colleagues (2014) themselves, yet they continue to believe that MCI always has prognostic value (e.g., Roberts,

PSYCHOLOGY AND GERIATRICS

Beyond Cognition

51

Knopman, Mielke, Cha, Pankratz, et al., 2014). Despite the evidence, or absence thereof, very few physicians have concluded that MCI, as currently measured, is not a clinical entity and therefore should not be treated (e.g., Gauthier & Touchon, 2005). A notable exception is the Food and Drug Administration (FDA). Given the lack of diagnostic clarity, there is currently no FDA-approved medication to prevent or treat MCI symptoms or progression, and both medical and psychological research have shown limited to no relationship between subjective memory complaint and objective memory performance. Instead, such complaints are more likely evidence of depression and low MSE mentioned earlier, than impaired cognition. This insight has led some to advocate removing subjective complaint from MCI diagnostic criteria (Lenehan, Klekociuk, & Summers, 2012). Nonetheless, in medical practice, “anti-dementia” drugs such as statins, AchEI, or Memantine, an NMDA antagonist – each of which has shown limited efficacy (e.g., Raschetti, Albanese, Vanacore, & Maggini, 2007) but consistent adverse side effects – continue to be prescribed “off label” for MCI management (Weinstein, Barton, Ross, Kramer, & Yaffe, 2009). In contrast, potentially beneficial behavioral interventions targeting self-efficacy enhancement or cognitive rehabilitation – shown to improve confidence and quality of life (Greenaway, Duncan, & Smith, 2013; Kurz, Pohl, Ramsenthaler, & Sorg, 2009; Regan & Varanelli, 2013) while posing little to no risk of harm – remain rare. The potential harm of this failure to integrate medical and behavioral approaches is not limited to geriatric patients and their families. In fact, a recent JAMA article promoted future trials of pharmacologic therapeutics aimed at “cognitively healthy but at-risk populations” (Friedrich, 2014). Because the number one known risk factor for Alzheimer’s disease is advanced age, the above description of “at-risk” includes us all. Should the entire nation really receive pharmacotherapy “just in case?” Physicians are not likely to become familiar with the aforementioned impact of psychological variables on cognition, including memory-related anxiety, confidence (self-efficacy), and even stereotypes. Collaboration with psychologists, on the other hand, might well enable a more comprehensive understanding and ability to differentiate between clinical (i.e., pathological) and nonclinical (normative) patterns of cognitive aging.

BEYOND COGNITION The relevance of patient beliefs to behavior extends well beyond cognition. Nearly 30 years ago psychologist Ann O’Leary reviewed the literature identifying self-efficacy’s role as mediator between health behavior

PSYCHOLOGY AND GERIATRICS

52

3.  Attitudes, Beliefs, and Behavior

interventions and their subsequent benefits (O’Leary, 1985). Interventions targeted smoking cessation relapse, pain management, eating and weight control, and recovery from myocardial infarction. Recently investigators have targeted self-management of chronic diseases such as hypertension, diabetes mellitus, heart disease, and arthritis. In a 2001 study, nurse Kate Lorig and colleagues (including Dr. Bandura himself) followed for 2 years a sample of 831 participants with history of heart disease, arthritis, or lung disease. Compared to a control group, participants trained in a chronic disease self-management program (CDSMP) showed significant increases in perceived self-efficacy and reductions in health distress, fewer visits to physicians or emergency rooms. Primary care medicine has also taken notice. A year later physicians joined Lorig in publishing a JAMA article that articulated the inseparable relationship between patient self-efficacy and chronic disease selfmanagement (Bodenheimer, Lorig, Holman, & Grumbach, 2002). In the 12 years since its publication, the article has been cited nearly 2000 times. CDC psychologist Teresa Brady and colleagues meta-analyzed 23 CDSMP studies and found program participants showed significant improvements in aerobic exercise, cognitive symptom management, stretching/ strengthening exercise, and psychological health up to 1 year after baseline, compared to nonparticipants (Brady et al., 2013).

ADHERENCE A vital and challenging concern likely to benefit from integrating behavioral and biomedical approaches to care is medication nonadherence, a prevalent behavior of epidemic proportions. Recent publications of the American Medical Association and American College of Physicians have acknowledged the associated costs – in terms of both health and economics (e.g., Butterfield, 2014; Zullig, Peterson, & Bosworth, 2013). While complex and multifactorial in nature, adherence is a behavior. Consistent with the above examples, beliefs and adherence go hand in hand. Examples of relevant patient and physician beliefs are listed in Boxes 3.1 and 3.2. As referenced earlier in this chapter, Zullig and colleagues recognized the clinical relevance of patient self-efficacy, referring to it by name in a recent JAMA article on successful ingredients for improving medication adherence. Yet nationally, the clinicians depended upon to translate these concepts and related theories into practice continue unfortunately to exclude psychologists, and include physicians, nurse practitioners (NP), and more recently, pharmacists. Below is a letter to the editor several colleagues and I submitted in response.

PSYCHOLOGY AND GERIATRICS

Adherence

BOX 3.1

C O M M O N PAT I E N T B E L I E F S AFFECTING ADHERENCE About Physician ● ● ● ● ● ● ● ● ● ●

Prescribing physician Prescribing physician Prescribing physician Prescribing physician Prescribing physician Prescribing physician Prescribing physician Prescribing physician Prescribing physician Prescribing physician medication properly.

is (not) an expert. cares about me. wants me to get better. knows why I am sick. knows how I can get better. is someone I can trust. is someone I should trust. trusts me. likes me. will (not) become angry if I do not take

About Self ● ● ● ● ● ●

I am (not) capable of understanding what to do to get better. I am (not) motivated to do what is necessary to get better. I (don’t) deserve to get better. I want to get better and don’t want to be sick. Eventually I will get better. I may never get better.

About Illness/Medication ● ● ● ● ● ● ●

Even if I don’t feel symptoms, I am still sick. Taking medication as directed will (not) help me. Benefits of medication (don’t) outweigh the side-effects. If I (don’t) take medication I will be worse off. No one really understands my illness-related pain. No one really knows what is wrong with me. Long-term side effects of medication are (not) dangerous.

PSYCHOLOGY AND GERIATRICS

53

54

3.  Attitudes, Beliefs, and Behavior

BOX 3.2

COMMON PHYSICIAN BELIEFS AFFECTING ADHERENCE About Patient ● ● ● ● ● ● ● ● ● ● ● ●

Patient needs and wants my expertise. Patient knows and feels I care about him/her. Patient wants help to get better. Patient does (not) know why he/she is sick. Patient will trust that I know how he/she can get better. Patient will listen and respect me. Patient must and will adhere to my recommendations. Patient needs me in order to get better. Patient must automatically trust me. Patient does trust me to help. Patient can (not) afford and access medication. Patient can (not) follow directions appropriately. Patient likes me. If patient does not take medication as prescribed, this shows he/she doesn’t want to get better. ● If patient does adhere to my directions, he/she will improve. ● If patient wants to get better, he/she will follow my advice. ● Patients always lie and cannot be trusted to take medication appropriately. ● ●

About Self ● ● ● ● ●



● ●

● ● ● ●

I should be respected. I am empathic when trying to help patients. I am capable of helping most patients. I care equally about all patients. Patient background and sociocultural factors do not influence how I see the patient. My decisions about medication are objective. Once I’ve prescribed medication and educated the patient, I have done my job. I cannot control whether patients take their medication. I should not have to control whether patients take their medication. I am unlikely to change a patient’s behavior. My role in supporting adherence is vital. continued

PSYCHOLOGY AND GERIATRICS

Adherence

55

BOX 3.2  (Cont’d) My clinical behavior will influence whether a patient trusts me and follows my advice.

●

About Illness/Medication Benefits of medication (don’t) outweigh the side-effects. Medication cannot be effective if it is not taken (appropriately). ● Efficacy of medication can only be trusted if shown in randomized controlled trials. ● It is easier to change medication than lifestyle. ● Adherence difficulty is (not) part of illness. ● ●

We commend the authors and journal for providing this much-needed list of “ingredients” for improving medication adherence. The article clearly demonstrates psychological insight into patient behavior, not surprising since the senior author is a psychologist. Adherence strategies and target outcomes are elucidated – “behavioral change and intervention strategies, managing patient perceptions, and supportive counseling” are all made explicit. The role of psychologists, however, is not. In fact, psychologists are never mentioned. Instead, physicians, nurse practitioners, and pharmacists are identified as the clinicians accountable for behavioral health. In terms of access, this makes sense, but in terms of training, it may not. Cost concerns and other factors continue to impede the delivery of integrated services. Currently, routine care generally includes patient contact with the aforementioned clinicians. Thus, they are, as the authors show, well-positioned to improve adherence. This standard of care does not include patient contact with clinical psychologists, whose precise focus is, in fact, managing behavior (including adherence). But perhaps it should. The authors target patient self-efficacy, an appropriate outcome of supportive counseling, given longstanding evidence linking self-efficacy to health-related behavior. But are physicians, nurse practitioners, and pharmacists adequately informed about this psychological construct theorized by a psychologist? If they are unfamiliar, who will help translate this theory into clinical practice? Now more than ever, academic medicine has recognized the link between behavior and health. Most notably, the Medical College Admissions Test (MCAT) will expand in 2015 to include psychological and behavioral science content for the first time in history. Though promising, practice implications are unknown. But if clinical psychologists do not provide direct patient care, nor help train those who do, can we truly expect suboptimal adherence rates to improve?

PSYCHOLOGY AND GERIATRICS

56

3.  Attitudes, Beliefs, and Behavior

Physician Michel Burnier and colleagues (2013) took quite a different perspective in their published review of drug adherence in resistant hypertension, informed by their belief that patients will never adequately take their medication on their own. They propose as a “solution” the avoidance of medication entirely, and instead, performance by physicians of invasive procedures (baroreflex stimulation and renal denervation). Further, if the procedures prove ineffective (which to date they have), their next recommended step is to perform them earlier. Integration to enhance physician-patient partnerships and implement well-established communication and behavioral management approaches such as motivational interviewing (e.g., Miller, 1982; Knight, McGowan, Dickens, & Bundy, 2006; Madson, Loignon, & Lane, 2009; Smedslund et al., 2011) are not considered. Again, as with the earlier cognitive aging examples, the prevailing attitude among many physicians is an earlier and/or procedurebased rather than integrated approach. To optimally treat the whole patient, this belief system must change (e.g., Bensadon, 2014). To be clear, it is extremely encouraging to note the medical profession is beginning to recognize the behavioral and psychosocial (i.e., psychological) impact, needs, and management options associated with medical illness. Geriatric patients in particular, for whom polypharmacy and multimorbidity are common, can benefit greatly from nonpharmacologic options in terms of both safety and quality of life. Yet when it comes to care provision, clinical psychologists are consistently and conspicuously absent. While the above articles are on the right track, calling for nonpsychologists to ask screening questions about mood, translate psychological theory into practice, and recognize the often subtle cues of caregiving-associated psychological burden, are not sufficient to influence physicians’ beliefs and practice behavior.

UNCOMFORTABLE DISCUSSIONS As with adherence, well-intentioned but ineffective management recommendations for physicians surround the frequency and quality of “uncomfortable” discussion about end of life, driving cessation, and suicide. Decades of evidence have shown that in medical practice, each has been and remains suboptimal (Ahluwalia, Levin, Lorenz, & Gordon, 2013; Hofmann et al., 1997; Tulsky, Fischer, Rose, & Arnold, 1998). Nonetheless, while some physicians have advocated for an interdisciplinary approach to address the behavioral aspects of care (e.g., Carr & Ott, 2010), and revealed their own low self-confidence or self-efficacy beliefs in these areas (e.g., Brown & Ott, 2004; Jang et al., 2007), enhanced clinical integration is generally not emphasized. Rather, to address these challenges, the focus continues to be utility and perpetual refinement of decision aids,

PSYCHOLOGY AND GERIATRICS

Physician Beliefs

57

algorithms, and other research “tools” (e.g., Lee, Brummel-Smith, Meyer, Drew, & London, 2000; Lau, Cloutier-Fisher, Kuziemsky, Black, Downing, Borycki, et al., 2007). Evidence suggests this approach is misguided. More than a decade has passed since the American Medical Association first published formal guidelines for physician assessment of older drivers in 2003 but a 2013 literature review of such assessment found no evidence of benefit (Martin, Marottoli, O’Neill, 2013). A 1997 review article evaluated 20 “new” suicide assessment instruments (Range & Knott, 1997) but about 10 years later as many as 83% of people completing suicides were seen but apparently neither recognized nor adequately managed as suicidal by a primary care physician within the same year of their death and 66% within the same month (Mann et al., 2005). A 2007 review of measures of end-of-life care and outcomes asssessed 261 measures described in only a 15-year time frame (Mularski et al., 2007). Yet patients’ end-of-life care needs, especially when psychosocial more than medical, continue to go largely unmet (e.g., Davison, 2010; Hanson, Danis, & Garrett, 1997). While multiple factors may contribute to this disturbing clinical picture, one common theme remains constant. When it comes to clinical communication about psychologically uncomfortable areas of care such as driving cessation, end of life and suicide, it appears effective tools, while important in theory, are insufficient in practice (see Chapters 7–9). Clinical integration with psychologists, the professionals most thoroughly trained to not only understand but effectively manage human behavior, should help.

PHYSICIAN BELIEFS As clarified above, it is not just patients and caregivers who are guided by their beliefs. Unwavering allegiance to amyloid theories of dementia mentioned earlier represent but one piece of evidence that physicians, like nonphysicians, are similarly influenced. In a 1960 issue of JAMA, Newman and Nichols measured sexual activity and attitudes among older people and concluded that older people remain sexually interested and active in later life but declining health often coincides with declining sexual activity. Their take-home message for physicians was that discussion of sexual behavior should be standard in geriatric care, but all too often it is avoided. Underlying this message was a key psychological insight. Unlike other less socially stigmatized health concerns, sex is less likely to be introduced by older patients if their physician does not explicitly communicate (i.e., give permission) that doing so is acceptable. The likelihood that patients will raise the topic decreases further if they sense physicians’ discomfort or worse yet, disapproval. More recent calls to address the topic (e.g., Wilson, 2003), suggest it is just as relevant and apparently difficult to heed half a century later.

PSYCHOLOGY AND GERIATRICS

58

3.  Attitudes, Beliefs, and Behavior

Lindau and colleagues (2007) measured sexuality and health among 3005 older people aged 57–85 years old. Their data showed that prevalence of sexual activity declined with age but more than half the sample aged 65–74 was sexually active as were more than 25% of those 75–85 years old. While about half the entire sample reported at least one bothersome problem related to sexual function, only 38% of the men and 22% of the women reported ever discussing sex with their physician after turning age 50. In this context of “don’t ask, don’t tell” it is not surprising to learn that reported cases of both syphilis and chlamydia among adults aged 45–64 nearly tripled between 2000 and 2010 (Centers for Disease Control & Prevention). Particularly troubling and directly related is recent evidence that HIV diagnosis is more likely to come later among older patients than younger patients (e.g., Linley et al., 2012). Taylor and Gosney (2011) reviewed the literature on geriatric sexuality and concluded that clinicians’ decisions about whether to discuss sex are largely informed by their own personal attitudes, value systems, and beliefs in stereotypes. Psychiatrists are no less vulnerable to such bias and when evaluating depressed patients may be less likely to elicit a sexual history from older than younger individuals (Bouman & Arcelus, 2001). Physician belief-behavior links have been found in many other aspects of care. Harris and colleagues (2009) compared the views of primary care physicians (internists vs. family physicians) toward dementia care relative to other conditions. Among their key findings, compared to internists, family physicians more strongly believed they could improve quality of life among older patients with dementia. Not surprisingly, they also more strongly agreed that older patients should be routinely screened for dementia. Epstein and colleagues (1984) found correlations between physician attitudes about cost and placebo effects and their actual prescribing behavior. Pittet and colleagues (2004) found physician adherence to hand hygiene behavior was associated with their personal beliefs about being a role model for other colleagues, about whether they perceived hand hygiene as a behavioral norm and that nonadherence was risky, and whether they held a positive attitude toward such practice after patient contact. In a national sample, fewer primary care physicians screened for domestic violence than they did for other risks and fewer believed they knew how to screen or intervene, or that such interventions could be as successful as those for other health risks such as tobacco and HIV (Gerbert et al., 2002). In truth, the challenge of influencing physician behavior has been documented for decades. Davis and colleagues (1995) reviewed the literature of education strategies aimed at changing physician performance and health care outcomes from 1975 to 1994. Among the 160 interventions reviewed, specific strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifactorial approaches. On the whole, most strategies were ineffective at creating behavior change. Bloom’s (2005)

PSYCHOLOGY AND GERIATRICS

SENSITIZING LEARNERS TO CHRONIC DISEASE IMPACT: The Oklahoma Experience

59

review of 26 systematic reviews yielded a similar conclusion. Many physicians, themselves, have recognized the multifactorial nature of behavior change and the fact that interventions relying primarily on information alone, such as continuing medical education credits, is unlikely to suffice (Grimshaw et al., 2001; Shearn, 2001). At the system level, attempts to mitigate the risk of physicians’ own “nonadherence” to best practice guidelines (Cabana et al., 1999; Cohen, Halvorson, & Gosselink, 1994) have led to an aggressive push toward the practice of evidence-based medicine (EBM) in vogue today (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Consistent with this chapter’s theme, physicians’ beliefs and behavior, like those of non-physicians, appear inseparable. Indeed, Street and colleagues (2003) have shown that both physician and patient beliefs about control, and the respective behaviors that follow, influence each other during medical encounters. To help physicians recognize their beliefs and positively influence their behaviors, integrated programs in schools of medicine are beginning to take shape (e.g., Bensadon & Odenheimer, 2014b; Bensadon, Teasdale, & Odenheimer, 2013).

SENSITIZING LEARNERS TO CHRONIC DISEASE IMPACT: THE OKLAHOMA EXPERIENCE Effective integration with psychology, especially when physicians are still training (undergraduate and graduate) and developing their practicerelated beliefs and behaviors, allows them to be shown rather than told what to do. For example, at the University of Oklahoma College of Medicine, in an effort to sensitize future physicians to the impact of incurable chronic, neurodegenerative disease on both patients and their caregivers, we exposed fourth-year medical students to two dementia support groups – one for those carrying the diagnosis, one for their caregivers – as part of a required geriatrics clerkship (see Bensadon & Odenheimer, 2014a). Each group’s duration was 1.5 hours, and topics discussed included positive and negative experiences with the medical system. To assess student impact, we created and administered a brief anonymous survey to be completed immediately after the group, and asked students to submit a brief reflection essay within 48 hours. Overall, most students were astounded. In their essays they explicitly acknowledged a large training gap that this experience filled, and some pointed out this impact was felt both in their head (i.e., cognitively) and in their gut (i.e., affectively). Interestingly, a growing body of literature has established this connection, often referred to by gastroenterologists and neuroscientists as the gut-brain axis (e.g., Mayer, 2011). Some students cried, some called their parents to “check in,” and most thanked us for the experience, stating it reminded them of why they

PSYCHOLOGY AND GERIATRICS

60

3.  Attitudes, Beliefs, and Behavior

entered medicine in the first place. One student planning a career in surgery “confessed” via email that reading support group participant bios (circulated to students in advance) depressed him so intensely that he had to stop studying for the remainder of the evening. Our findings were particularly encouraging, given the widespread stereotypes (i.e., beliefs) within medical culture that clinical years of medical school inevitably lead to empathy erosion, and that surgery is an area of low sensitivity to begin with. Some data support these ideas (e.g., Bellini & Shea, 2005; Hojat et al., 2009; Tait, Chibnall, Luebbert, & Sutter, 2005), but our intervention and other data (e.g., Mangione et al., 2002) provide an important challenge to premature fatalism. Our support group experience led many students to reveal their own, sometimes strong, biases, such as an expectation that the group would be a “pity party.” But the intervention allowed even these students to spontaneously recognize and reflect on the inaccuracy of their preconceived notions, both about dementia and therapeutic support groups. This is particularly encouraging given the major stigma associated with both. It is also to be expected, given that most students’ previous exposure to this illness was limited to textbooks, neuroimaging, or inpatient settings with advance-stage patients. Additionally, their previous exposure to behavioral therapy was limited and shaped largely by that of their physician models prior to the experience. In contrast, the high-functioning, youngonset community-dwellers and their caregivers were similar in age to the medical students’ parents, another reason the exposure resonated personally with many learners. Without this evocative, community-based experience, medical trainee beliefs about neurodegenerative illness are likely skewed, something the students themselves were able to recognize via a relatively brief forum for introspection. While promising, support group exposure for practicing physicians and those in training remains virtually nonexistent. However, related attempts to destigmatize and humanize dementia are beginning to surface throughout the country, often in the guise of “mentor” or “buddy” programs matching medical trainees with volunteers living with the disease. In 2013 medical schools launching such programs included Boston University, Dartmouth, Washington University in St Louis, Kansas University, and Albany Medical College (American College of Physicians, 2014). Other experiential learning approaches that provide early introductions to aging and geriatric medicine are discussed later in this publication. Time will tell what impact such programs have on the attitudes, beliefs, and behavior of physicians, patients, and informal caregivers, but given the large number of chronic illness support groups nationally and the growing number of patients and families attending them to cope (Davison, Pennebaker, & Dickerson, 2000), their integration in medical training is warranted.

PSYCHOLOGY AND GERIATRICS

REFERENCES

61

References Adelman, R. D., Tmanova, L. L., Delgado, D., Dion, S., & Lachs, M. S. (2014). Caregiver burden: A clinical review. Journal of the American Medical Association, 311(10), 1052–1060. Ahluwalia, S. C., Levin, J. R., Lorenz, K. A., & Gordon, H. S. (2013). “There’s no cure for this condition”: How physicians discuss advance care planning in heart failure. Patient Education and Counseling, 91(2), 200–205. Allport, G. W. (1954). The nature of prejudice. Reading: Addison-Wesley. American College of Physicians (2014). Alzheimer’s patients preapre, enlighten future physicians. ACP Internist website. Retrieved from: . Arkes, H. R., & Blumer, C. (1985). The psychology of sunk cost. Organizational Behavior and Human Decision Processes, 35(1), 124–140. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. Bellini, L. M., & Shea, J. A. (2005). Mood change and empathy decline persist during three years of internal medicine training. Academic Medicine, 80(2), 164–167. Bensadon, B.A. (2010). Memory self-efficacy and stereotype effects in aging. (Unpublished doctoral dissertation). Available from ProQuest Dissertations and Theses database. (Order No. 856603225). University of Florida, Gainesville, Florida. Bensadon, B. A. (2014). Maximizing treatment adherence: Physician-patient partnerships vs. procedures. Hypertension, 63, e7. Bensadon, B. A., & Odenheimer, G. L. (2013). Current management decisions in mild cognitive impairment. Clinics in Geriatric Medicine, 29(4), 847–871. Bensadon, B. A., & Odenheimer, G. L. (2014a). Understanding chronic disease: Student exposure to support groups. Medical Education, 48(5), 526–527. Bensadon, B. A., & Odenheimer, G. L. (2014b). Listening to our elders: A story of resilience and recovery. Patient Education and Counseling, 95(3), 433–434. Bensadon, B. A., Teasdale, T. A., & Odenheimer, G. L. (2013). Attitude adjustment: Shaping medical students’ perceptions of older patients with a geriatrics curriculum. Academic Medicine, 88(11), 1630–1634. Berry, J. M., West, R. L., & Dennehy, D. M. (1989). Reliability and validity of the memory self-efficacy questionnaire. Developmental Psychology, 25(5), 701–713. Bloom, B. S. (2005). Effects of continuing medical education on improving physician clinical care and patient health: A review of systematic reviews. International Journal of Technology Assessment in Health Care, 21(3), 380–385. Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002). Patient self-management of chronic disease in primary care. Journal of the American Medical Association, 288(19), 2469–2475. Bouman, W. P., & Arcelus, J. (2001). Are psychiatrists guilty of ageism when it comes to taking a sexual history? International Journal of Geriatric Psychiatry, 16, 27–31. Brady, T. J., Murphy, L., O’Colmain, B. J., Beauchesne, D., Daniels, B., Greenberg, M., et al. (2013). A meta-analysis of health status, health behaviors, and health care utilization outcomes of the chronic disease self-management program. Preventing Chronic Disease, 10, 120112. Brown, L. B., & Ott, B. R. (2004). Driving and dementia: A review of the literature. Journal of Geriatric Psychiatry & Neurology, 17(4), 232–240. Bruckert, E., Hayem, G., Dejager, S., Yau, C., & Begaud, B. (2005). Mild to moderate muscular symptoms with high-dosage statin therapy in hyperlipidemic patients – The primo study. Cardiovascular Drugs and Therapy, 19(6), 403–414. Burnier, M., Wuerzner, G., Struijker-Boudier, H., & Urquhart, J. (2013). Measuring, analyzing, and managing drug adherence in resistant hypertension. Hypertension, 62, 218–225. Butler, R. N. (1969). Ageism: Another form of bigotry. Gerontologist, 9, 243–246.

PSYCHOLOGY AND GERIATRICS

62

3.  Attitudes, Beliefs, and Behavior

Butler, R. N. (1975). Why Survive? Being Old in America. New York: Harper & Row. Butterfield, S. (2014, May). Treat the epidemic of medical nonadherence. ACP Internist website. Retrieved from: . Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P. A. C., et al. (1999). Why don’t physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association, 282(15), 1458–1465. Cain, D. M., & Detsky, A. S. (2008). Everyone’s a little bit biased (even physicians). Journal of the American Medical Association, 299(24), 2893–2895. Carr, D. B., & Ott, B. R. (2010). The older adult driver with cognitive impairment “It’s a very frustrating life.”. Journal of the American Medical Association, 303(16), 1632–1641. Chien, L. Y., Chu, H., Guo, J. L., Liao, Y. M., Chang, L. I., Chen, C. H., et al. (2011). Caregiver support groups in patients with dementia: a meta‐analysis. International Journal of Geriatric Psychiatry, 26(10), 1089–1098. Cohen, S. J., Halvorson, H. W., & Gosselink, C. A. (1994). Changing physician behavior to improve disease prevention. Preventive Medicine, 23(3), 284–291. Dark-Freudeman, A., West, R. L., & Viverito, K. M. (2006). Future selves and aging: Older adults’ memory fears. Educational Gerontology, 32(2), 85–109. Davis, D. A., Thomson, M. A., Oxman, A. D., & Haynes, R. B. (1995). Changing physician performance: A systematic review of the effect of continuing medical education strategies. Journal of the American Medical Association, 274(9), 700–705. Davison, K. P., Pennebaker, J. W., & Dickerson, S. S. (2000). Who talks? The social psychology of illness support groups. American Psychologist, 55(2), 205–217. Davison, S. N. (2010). End-of-life care preferences and needs: Perceptions of patients with chronic kidney disease. Clinical Journal of the American Society of Nephrology, 5(2), 195–204. DeSalvo, K. B., Bloser, N., Reynolds, K., He, J., & Muntner, P. (2006). Mortality prediction with a single general self-rated health question: A meta-analysis. Journal of General Internal Medicine, 21(3), 267–275. DeSalvo, K. B., & Muntner, P. (2011). Discordance between physician and patient self-rated health and all-cause mortality. The Ochsner Journal, 3, 232–240. Dunkin, J. J., & Anderson-Hanley, C. (1998). Dementia caregiver burden: A review of the literature and guidelines for assessment and intervention. Neurology, 51(1), S53–S60. Epstein, A. M., Read, J. L., & Winickoff, R. (1984). Physician beliefs, attitudes, and prescribing behavior for anti-inflammatory drugs. The American Journal of Medicine, 77(2), 313–318. Evans, M. A., & Golomb, B. A. (2009). Statin-associated adverse cognitive effects: Survey results from 171 patients. Pharmacotherapy: The Journal of Human Pharmacology & Drug Therapy, 29(7), 800–811. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. Friedman, M., & Rosenman, R. H. (1959). Association of specific overt behavior pattern with blood and cardiovascular findings: Blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease. Journal of the American Medical Association, 169(12), 1286–1296. Friedman, M., & Rosenman, R. H. (1974). Type A Behavior and Your Heart. New York: Knopf. Friedrich, M. J. (2012). New research on Alzheimer treatments ventures beyond plaques and tangles. Journal of the American Medical Association, 308(24), 2553–2555. Friedrich, M. J. (2014). Researchers test strategies to prevent Alzheimer disease. Journal of the American Medical Association, 311(16), 1596–1598. Gauthier, S., & Touchon, J. (2005). Mild cognitive impairment is not a clinical entity and should not be treated. Archives of Neurology, 62(7), 1164–1166. Gauthier, S., Reisberg, B., Zaudig, M., Petersen, R. C., Ritchie, K., & Broich, K., et al. (2006). Mild cognitive impairment. The Lancet, 367(9518), 1262–1270.

PSYCHOLOGY AND GERIATRICS

REFERENCES

63

George, D. R., & Whitehouse, P. J. (2014). Chasing the “White Whale” of Alzheimer’s. Journal of the American Geriatrics Society, 62(3), 588–589. Gerbert, B., Gansky, S. A., Tang, J. W., McPhee, S. J., Carlton, R., Herzig, K., et al. (2002). Domestic violence compared to other health risks: a survey of physicians’ beliefs and behaviors. American Journal of Preventive Medicine, 23(2), 82–90. Golomb, B. A., McGraw, J. J., Evans, M. A., & Dimsdale, J. E. (2007). Physician response to patient reports of adverse drug effects. Drug Safety, 30(8), 669–675. Greenaway, M. C., Duncan, N. L., & Smith, G. E. (2013). The memory support system for mild cognitive impairment: Randomized trial of a cognitive rehabilitation intervention. International Journal of Geriatric Psychiatry, 28(4), 402–409. Grimshaw, J. M., Shirran, L., Thomas, R., Mowatt, G., Fraser, C., Bero, L., et al. (2001). Changing provider behavior: An overview of systematic reviews of interventions. Medical Care, 39, II2–II45. Hanson, L. C., Danis, M., & Garrett, J. (1997). What is wrong with end-of-life care? Opinions of bereaved family members. Journal of the American Geriatrics Society, 45(11), 1339–1344. Harris, D. P., Chodosh, J., Vassar, S. D., Vickrey, B. G., & Shapiro, M. F. (2009). Primary care providers’ views of challenges and rewards of dementia care relative to other conditions. Journal of the American Geriatrics Society, 57(12), 2209–2216. Hess, T. M., Auman, C., Colcombe, S. J., & Rahhal, T. A. (2003). The impact of stereotype threat on age differences in memory performance. Journals of Gerontology: Psychological Sciences, 58B(1), P3–P11. Hess, T. M., & Hinson, J. T. (2006). Age-related variation in the influences of aging stereotypes on memory in adulthood. Psychology and Aging, 21(3), 621–625. Hess, T. M., Hinson, J. T., & Hodges, E. A. (2009). Moderators of and mechanisms underlying stereotype threat effects on older adults’ memory performance. Experimental Aging Research, 35(2), 153–177. Hess, T. M., Hinson, J. T., & Statham, J. A. (2004). Explicit and implicit stereotype activation effects on memory: Do age and awareness moderate the impact of priming? Psychology and Aging, 19(3), 495–505. Hofmann, J. C., Wenger, N. S., Davis, R. B., Teno, J., Connors, A. F., Desbiens, N., et al. (1997). Patient preferences for communication with physicians about end-of-life decisions. Annals of Internal Medicine, 127(1), 1–12. Hojat, M., Vergare, M. J., Maxwell, K., Brainard, G., Herrine, S. K., Isenberg, G. A., et al. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Academic Medicine, 84(9), 1182–1191. Hundt, N. E., Bensadon, B. A., Stanley, M. A., Petersen, N. J., Kunik, M. E., Kauth, M. R., et al. (2013). Coping mediates the relationship between disease severity and illness intrusiveness among chronically ill patients. Journal of Health Psychology Epub 2013 December 1. Idler, E., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21–37. Jang, R. W., Man-Son-Hing, M., Molnar, F. J., Hogan, D. B., Marshall, S. C., Auger, J., et al. (2007). Family physicians’ attitudes and practices regarding assessments of medical fitness to drive in older persons. Journal of General Internal Medicine, 22(4), 531–543. Knight, K. M., McGowan, L., Dickens, C., & Bundy, C. (2006). A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology, 11(2), 319–332. Kotter-Gruhn, D., & Hess, T. M. (2012). The impact of age stereotypes on self-perceptions of aging across the adult lifespan. Journals of Gerontology B: Psychological Sciences & Social Sciences, 67(5), 563–571. Kurz, A., Pohl, C., Ramsenthaler, M., & Sorg, C. (2009). Cognitive rehabilitation in patients with mild cognitive impairment. International Journal of Geriatric Psychiatry, 24(2), 163–168.

PSYCHOLOGY AND GERIATRICS

64

3.  Attitudes, Beliefs, and Behavior

Lau, F., Cloutier-Fisher, D., Kuziemsky, C., Black, F., Downing, M., Borycki, E., et al. (2007). A systematic review of prognostic tools for estimating survival time in palliative care. Journal of Palliative Care, 23(2), 93–112. Lee, M. A., Brummel-Smith, K., Meyer, J., Drew, N., & London, M. R. (2000). Physician orders for life-sustaining treatment (POLST): Outcomes in a PACE program. Program of AllInclusive Care for the Elderly. Journal of the American Geriatrics Society, 48(10), 1219–1225. Lenehan, M. E., Klekociuk, S. Z., & Summers, M. J. (2012). Absence of a relationship between subjective memory complaint and objective memory impairment in mild cognitive impairment (MCI): Is it time to abandon subjective memory complaint as an MCI diagnostic criterion? International Psychogeriatrics, 24(9), 1505–1514. Levy, B. (1996). Improving memory in old age through implicit self-stereotyping. Journal of Personality and Social Psychology, 71(6), 1092–1107. Levy, B. (2000). Handwriting as a reflection of aging self-stereotypes. Journal of Geriatric Psychiatry. Levy, B. R. (2003). Mind matters: Cognitive and physical effects of aging self-stereotypes. Journals of Gerontology: Psychological Sciences, 58B(4), P203–P211. Levy, B. (2009). Stereotype embodiment: A psychosocial approach to aging. Current Directions in Psychological Science, 18(6), 332–336. Levy, B.R., & Banaji, M.R. (2002). Implicit ageism. In T.D. Nelson (Ed.): Ageism: Stereotyping and Prejudice Against Older Persons, 49–75. Levy, B. R., Hausdorff, J. M., Hencke, R., & Wei, J. Y. (2000). Reducing cardiovascular stress with positive self-stereotypes of aging. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 55(4), P205–P213. Levy, B. R., Slade, M. D., Kunkel, S. R., & Kasl, S. V. (2002). Longevity increased by positive self-perceptions of aging. Journal of Personality and Social Psychology, 83(2), 261–270. Levy, B., & Langer, E. (1994). Aging free from negative stereotypes: Successful memory in China among the American deaf. Journal of Personality and Social Psychology, 66(6), 989–997. Levy, B. R., Zonderman, A. B., Slade, M. D., & Ferrucci, L. (2009). Age stereotypes held earlier in life predict cardiovascular events in later life. Psychological Science, 20(3), 296–298. Levy, B. R., Zonderman, A. B., Slade, M. D., & Ferrucci, L. (2012). Memory shaped by age stereotypes over time. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 67(4), 432–436. Levy, B. R., Slade, M. D., & Kasl, S. V. (2002). Longitudinal benefit of positive self-perceptions of aging on functional health. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 57(5), P409–P417. Levy, B. R., Slade, M. D., Chung, P. H., & Gill, T. M. (2014). Resiliency over time of elders’ age stereotypes after encountering stressful events. Journals of Gerontology B: Psychological Sciences & Social Sciences, 61B, P82–P87. Levy, B. R., Slade, M. D., Murphy, T. E., & Gill, T. M. (2012). Association between positive age stereotypes and recovery from disability in older persons. Journal of the American Medical Association, 308(19), 1972–1973. Lindau, S. T., Schumm, L. P., Laumann, E. O., Levinson, W., O’Muircheartaigh, C. A., & Waite, L. J. (2007). A study of sexuality and health among older adults in the United States. New England Journal of Medicine, 357(8), 762–774. Linley, L., Prejean, J., An, Q., Chen, M., & Hall, H. I. (2012). Racial/ethnic disparities in HIV diagnoses among persons aged 50 years and older in 37 US states, 2005–2008. American Journal of Public Health, 102(8), 1527–1534. Lorig, K. R., Ritter, P., Stewart, A. L., Sobel, D. S., Brown, B. W., Jr., Bandura, A., et al. (2001). Chronic disease self-management program 2-year health status and health care utilization outcomes. Medical Care, 39(11), 1217–1223. Madson, M. B., Loignon, A. C., & Lane, C. (2009). Training in motivational interviewing: A systematic review. Journal of Substance Abuse Treatment, 36(1), 101–109.

PSYCHOLOGY AND GERIATRICS

REFERENCES

65

Mangione, S., Kane, G. C., Caruso, J. W., Gonnella, J. S., Nasca, T. J., & Hojat, M. (2002). Assessment of empathy in different years of internal medicine training. Medical Teacher, 24(4), 370–373. Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., et al. (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association, 294(16), 2064–2074. Martin, A. J., Marottoli, R., & O’Neill, D. (2013). Driving assessment for maintaining mobility and safety in drivers with dementia. Cochrane Database Systematic Review, 8. Mayer, E. A. (2011). Gut feelings: the emerging biology of gut-brain communication. Nature Reviews Neuroscience, 12, 453–466. McGuinness, B., O’Hare, J., Craig, D., Bullock, R., Malouf, R., & Passmore, P. (2013). Cochrane review on ‘statins for the treatment of dementia’. International Journal of Geriatric Psychiatry, 28(2), 119–126. Miller, W. R. (1982). Motivational interviewing with problem drinkers. Behavioural Psychotherapy, 11(2), 147–172. Mossey, J. M., & Shapiro, E. (1982). Self-rated health: A predictor of mortality among the elderly. American Journal of Public Health, 72(8), 800–808. Mularski, R. A., Dy, S. M., Shugarman, L. R., Wilkinson, A. M., Lynn, J., Shekelle, P. G., et al. (2007). A systematic review of measures of end‐of‐life care and its outcomes. Health Services Research, 42(5), 1848–1870. Newman, G., & Nichols, C. R. (1960). Sexual activities and attitudes in older persons. Journal of the American Medical Association, 173(1), 33–35. O’Leary, A. (1985). Self-efficacy and health. Behaviour Research and Therapy, 23(4), 437–451. Perri, R., Carlesimo, G. A., Serra, L., & Caltagirone, C. (2009). When the amnestic mild cognitive impairment disappears. Cognitive Behavioral Neurology, 22(2), 109–116. Perri, R., Serra, L., Carlesimo, G. A., & Caltagirone, C. (2007). Preclinical dementia: An Italian multicenter study on amnestic mild cognitive impairment. Dementia and Geriatric Cognitive Disorders, 23, 289–300. Petersen, R. C., Roberts, R. O., Knopman, D. S., Boeve, B. F., Geda, Y. E., Ivnik, R. J., et al. (2009). Mild cognitive impairment: Ten years later. Archives of Neurology, 66(12), 1447–1455. Petersen, R. C., Smith, G. E., Ivnik, R. J., Tangalos, E. G., & Kokmen, E. (1994). Memory function in very early Alzheimer’s. Neurology, 44(5), 867–872. Petersen, R. C., Smith, G. E., Waring, S. C., Ivnik, R. J., Tangalos, E. G., & Kokmen, E. (1999). Mild cognitive impairment: clinical characterization and outcome. Archives of Neurology, 56(3), 303–308. Pittet, D., Simon, A., Hugonnet, S., Pessoa-Silva, C., Sauvan, V., & Perneger, T. V. (2004). Hand hygiene among physicians: Performance, beliefs, and perceptions. Annals of Internal Medicine, 141, 1–8. Range, L. M., & Knott, E. C. (1997). Twenty suicide assessment instruments: Evaluation and recommendations. Death Studies, 21(1), 25–58. Raschetti, R., Albanese, E., Vanacore, N., & Maggini, M. (2007). Cholinesterase inhibitors in mild cognitive impairment: A systematic review of randomised trials. PLoS Medicine, 4(11), e338. Regan, B., & Varanelli, L. (2013). Adjustment, depression, and anxiety in mild cognitive impairment and early dementia: A systematic review of psychological intervention studies. International Psychogeriatrics, 25(12), 1963–1984. Reuben, D., Levin, J., Frank, J., Hirsch, S., McCreath, H., Roth, C., et al. (2009). Closing the dementia care gap: Can referral to Alzheimer’s Association chapters help? Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 5(6), 498–502. Reuben, D. B., Roth, C. P., Frank, J. C., Hirsch, S. H., Katz, D., & McCreath, H., et al. (2010). Assessing care of vulnerable elders—Alzheimer’s disease: A pilot study of a practice redesign intervention to improve the quality of dementia care. Journal of the American Geriatrics Society, 58(2), 324–329.

PSYCHOLOGY AND GERIATRICS

66

3.  Attitudes, Beliefs, and Behavior

Roberts, R. O., Knopman, D. S., Mielke, M. M., Cha, R. H., Pankratz, V. S., Christianson, T. J., et al. (2014). Higher risk of progression to dementia in mild cognitive impairment cases who revert to normal. Neurology, 82(4), 31–325. Sackett, D. L., Rosenberg, W., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312(7023), 71–72. Shearn, D. (2001). Changing physician behavior: What does it take? Western Journal of Medicine, 175(3), 167. Smedslund, G., Berg, R. C., Hammerstrøm, K. T., Steiro, A., Leiknes, K. A., Dahl, H. M., et al. (2011). Motivational interviewing for substance abuse. Cochrane Database Systematic Reviews(5), CD008063. Smith, G. E., Petersen, R. C., Parisi, J. E., Ivnik, R. J., Kokmen, E., Tangalos, E. G., et al. (1996). Definition, course, and outcome of mild cognitive impairment. Aging Neuropsychology & Cognition, 3, 131–147. Steele, C. M., & Aronson, J. (1995). Stereotype threat and the intellectual test performance of African Americans. Journal of Personality and Social Psychology, 69(5), 797–811. Steele, C. M. (1997). A threat in the air: How stereotypes shape intellectual identity and performance. American Psychologist, 52(6), 613–629. Street, R. L., Krupat, E., Bell, R. A., Kravitz, R. L., & Haidet, P. (2003). Beliefs about control in the physician‐patient relationship. Journal of General Internal Medicine, 18(8), 609–616. Tait, R. C., Chibnall, J. T., Luebbert, A., & Sutter, C. (2005). Effect of treatment success and empathy on surgeon attributions for back surgery outcomes. Journal of Behavioral Medicine, 28(4), 301–312. Taylor, A., & Gosney, M. A. (2011). Sexuality in older age: Essential considerations for health care professionals. Age and Ageing, 40(5), 538–543. Thompson, C. A., Spilsbury, K., Hall, J., Birks, Y., Barnes, C., & Adamson, J. (2007). Systematic review of information and support interventions for caregivers of people with dementia. BMC Geriatrics, 7(1), 18. Tulsky, J. A., Fischer, G. S., Rose, M. R., & Arnold, R. M. (1998). Opening the black box: How do physicians communicate about advance directives? Annals of Internal Medicine, 129(6), 441–449. Tversky, A., & Kahneman, D. (1974). Judgment under uncertainty: Heuristics and biases. Science, 185(4157), 1124–1131. Weinstein, A. M., Barton, C., Ross, L., Kramer, J. H., & Yaffe, K. (2009). Treatment practices of mild cognitive impairment in California Alzheimer’s disease centers. Journal of the American Geriatrics Society, 57(4), 686–690. West, R. L., Bagwell, D. K., & Dark-Freudeman, A. (2005). Memory and goal setting: The response of older and younger adults to positive and objective feedback. Psychology & Aging, 20(2), 195–201. West, R. L., Bagwell, D. K., & Dark-Freudeman, A. (2008). Self-efficacy and memory aging: The impact of a memory intervention based on self-efficacy. Aging, Neuropsychology, and Cognition, 15(3), 302–329. West, R. L., Crook, T. H., & Barron, K. L. (1992). Everyday memory performance across the life span: Effects of age and noncognitive individual differences. Psychology and Aging, 7(1), 72–82. West, R. L., Dark-Freudeman, A., & Bagwell, D. K. (2009). Goals-feedback conditions and memory: Mechanisms for memory gains in older and younger adults. Memory, 17(2), 233–244. West, R. L., Dennehy-Basile, D., & Norris, M. P. (1996). Memory self-evaluation: The effects of age and experience. Aging, Neuropsychology, and Cognition, 3(1), 67–83. West, R. L., Thorn, R. M., & Bagwell, D. K. (2003). Memory performance and beliefs as a function of goal setting and aging. Psychology and Aging, 18(1), 111–125. West, R. L., Welch, D. C., & Knabb, P. D. (2002). Gender and aging: Spatial self-efficacy and location recall. Basic and Applied Social Psychology, 24(1), 71–80.

PSYCHOLOGY AND GERIATRICS

REFERENCES

67

West, R. L., Welch, D. C., & Thorn, R. M. (2001). Effects of goal-setting and feedback on memory performance and beliefs among older and younger adults. Psychology and Aging, 16, 240–250. West, R. L., & Yassuda, M. S. (2004). Aging and memory control beliefs: Performance in relation to goal setting and memory self-evaluation. Journals of Gerontology: Psychological Sciences, 59B(2), 56–65. Wilson, M. M. (2003). Sexually transmitted diseases. Clinics in Geriatric Medicine, 19(3), 637–655. Zarit, S. H., Reever, K. E., & Bach-Peterson, J. (1980). Relatives of the impaired elderly: Correlates of feelings of burden. The Gerontologist, 20(6), 649–655. Zarit, S. H., Todd, P. A., & Zarit, J. M. (1986). Subjective burden of husbands and wives as caregivers: A longitudinal study. The Gerontologist, 26(3), 260–266. Zullig, L. L., Peterson, E. D., & Bosworth, H. B. (2013). Ingredients of successful interventions to improve medication adherence. Journal of the American Medical Association, 310(24), 2611–2612.

PSYCHOLOGY AND GERIATRICS